Basic Information
| Provider Information | |||||||||
| NPI: | 1326076498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 N 29TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028448121 | ||||||||
| FaxNumber: | 4028448122 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 N 29TH ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028444828 | ||||||||
| FaxNumber: | 4028448175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 110665 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 10025561900 | 05 | NE | MEDICAID |